1174891980 NPI number — SOUTHSIDE PHYSICAL THERAPY AND SPORTS CENTER

Table of content: (NPI 1174891980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174891980 NPI number — SOUTHSIDE PHYSICAL THERAPY AND SPORTS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE PHYSICAL THERAPY AND SPORTS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174891980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22311 BROOKHURST ST STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92646-8458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-965-2222
Provider Business Mailing Address Fax Number:
714-965-2224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22311 BROOKHURST ST STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92646-8458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-965-2222
Provider Business Practice Location Address Fax Number:
714-965-2224
Provider Enumeration Date:
12/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CARLOS
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
RAMON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-965-2222

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT26966 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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